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08234040035 <br /> a <br /> Waste Tire Survey $ Inspection Report Inspection Report Number <br /> Stata°tt:a"`°`nla I 1 1088164 <br /> CM/Ma,6,(Haw eaoa,'. Survey Form Page1 <br /> caltfomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID. n u Inspection Type (Fill one) <br /> Site Suffix: <br /> [ES 3 7 CJ 1� Q Q Routine Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: San 'ToCk qLAI n C- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> inspected By Inspector <br /> Chit:ro_ke e T+rts IWh_eeLS 3 9 <br /> Physical Address M01 <br /> L&r_i.gfii qp LucaSJ <br /> X5_21 N—C1,ar_o ke e_L.rl. I — • <br /> Street �1 Inspection Date <br /> L—Lo_d+ - -CA 9-�` 2- LL0j Time In Time Out <br /> City State ZIP Code <br /> Business Rep Title 0 AM O AM <br /> 1=' O PM 'L�_I O PM <br /> D_REES^S_1��O1�R_ --�_Tern_L.,a►laorer, <br /> - - — Operational Status Tire Type Business Role Storage Type. <br /> I (Fillonsonly) (Fllallthat apply) -(Fill all that apply) (Fill all that apply) <br /> The Count(Whole/PTE) <br /> 2 01 .Active 0 Passenger ' Generator 6 Outdoor <br /> i Q Closed Q Altered <br /> GPS Latitude I •I i Q Hauler Q Indoor' <br /> — L--_--- .-1__---- Q Inactive Q Truck <br /> --r — -- i—:--i 7--�0 <br /> Longitude Q O <br /> OTR Q End-Use Q Container <br /> Planned <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader .Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / ED <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Requved for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2:Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14.CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators - •In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments ` <br /> tr.►. vCI-:�_ac:►1��ct1 ha�_gp.prox..220_ eta is es Sta_r_ed_on-51 E. Prevlofta- <br /> -'Llij41.n}irle, ly Co d Q959 510rcit —ts��a-ks fres-9tctdoor <br /> )nos beenc�c ecL.��.n of atio_na—or ar_�,gs— con e_etn <br /> Inspection Form Included:Q <br /> z Li <br /> Comments Included:Qa - - - _ -� <br /> Efusiness Re Ignature Phone Number ins ct is Signature Phone Number <br /> INSTRUCTIONS ON BACK Co� Incorrect: ( 9 1 ENJ AIMIP L I Ef <br /> 62081 <br /> ■ While py.CIW Yellow Copy.Operator Pink Copy.LEA ® ■ <br />